Provider Demographics
NPI:1407160815
Name:DESHAW, JONATHAN GLENN (OD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:GLENN
Last Name:DESHAW
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2636 W WALNUT ST STE 200
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75042-6441
Mailing Address - Country:US
Mailing Address - Phone:972-485-0700
Mailing Address - Fax:972-485-0702
Practice Address - Street 1:2636 W WALNUT ST STE 200
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75042-6441
Practice Address - Country:US
Practice Address - Phone:972-485-0700
Practice Address - Fax:972-485-0702
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-28
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7628TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist